Regional Partnership Information - Maryland · Web viewProgram Partners in FY 2018 Please list any community based organizations, contractors, and/or public partners AUTOMATED SECURITY

HSCRC Transformation Grant – Performance Year 2 (FY 2018) Report Template – TLC-MD

HSCRC Transformation GrantFY 2018 Report

The Health Services Cost Review Commission (HSCRC) is reviewing the following for FY 2018: this Report, the Budget Report, and the Budget Narrative. Whereas the Budget Report distinguishes between each hospital, this Report should describe all hospitals, if more than one, that are in the Regional Partnership.

Regional Partnership InformationRegional Partnership (RP) Name Totally Linking Care in Maryland (TLC-MD)

RP Hospital(s) 1. Calvert Memorial Hospital2. Doctors Community Hospital3. Ft Washington Medical Center4. MedStar Southern Maryland Hospital5. MedStar St. Mary’s Hospital6. UMS Capital Regional Medical Center (formally Laurel

Regional Hospital)7. UMS Capital Regional Medical Center (formally Prince

George’s Hospital Center)

RP POC David Chernov, Executive Director

RP Interventions in FY 2018 1. Community Health Worker Program2. eqHealth Solutions for Care Management3. HQI Blue Bag Rx Program4. P3 Medication Adherence Program5. ASA Medication Adherence Tele Health Devices

Total Budget in FY 2018Please insert FY 2017 award and FY 2018 award.

FY 2017 Award: $1,200,000

FY 2018 Award: $1,080,000

Total FTEs in FY 2018 Employed: 0

Contracted: 1 FTE as of June 1, 2018 (0.08 FTE for FY2018)

Program Partners in FY 2018Please list any community based organizations, contractors, and/or public partners

1. AUTOMATED SECURITY ALERT2. EQHEALTH SOLUTIONS, INC.3. PRINCE GEORGES FIRE DEPARTMENT4. RCM&D5. PRINCE GEORGES DEPARTMENT OF HEALTH6. HQI

1


Overall Summary of Regional Partnership Activities in FY 2018 (Free Response: 1-3 Paragraphs):

FY 2018 was a year of finalization of building the infrastructure to deliver interventions and ensuring consistency among hospitals in the care coordination at the hospital and in the home of the participants. It included review of the care coordination interventions, medication management and an appropriate data logic model. First, the hospitals developed a standard community health worker (CHW) program and implemented it with the hospital staff, the eQHealth staff and the local departments of health. The data committee is assisting in documenting whether the use of CHW as employees of the hospital (Calvert and MedStar St Mary’s), or employees of eQHealth (Doctors), or employees of Prince George’s DOH (all other hospitals) are best for participant outcomes. The Data Committee and Clinical Committee meet together to ensure new interventions can be documented and results reported. Prior to this year, results were based on volume of services provided and now we are working on value to obtain desirable outcomes.

Second, TLC-MD continued to expand the HQI Blue Bag Rx Program in which blue bags are located in physicians’ offices to encourage patients to return unused or expired prescription and over the counter medications. During the year, TLC-MD’s Clinical Committee began to identify Pharmacists champions at each hospital to facilitate the monthly data collection sheets. Goals this year are to easily facilitate the data extraction and results.

Third, the P3 Medication and Tele Health devices are still under review. Many hospitals implemented the Tele Health devices but are reporting mixed results. The P3 Medication program was delayed until FY 2019 due to the previously mentioned efforts in FY 2018 that required a standardized effort among hospitals to capture participants and their results, before taking on another major project, like P3. For the P3 program to be effective, the eQHealth pharmacist assessment / survey tool is under review to ensure the P3 staff can view the medication list. P3 has telephone and remote monitoring devices capabilities via secure Skype-type system.

2


Intervention Program Please repeat this section for each Intervention/Program that your Partnership maintains, if more than one.

Intervention or Program Name

1. Community Health Worker Program

RP Hospitals Participating in InterventionPlease indicate if All; otherwise, please indicate which of the RP Hospitals are participating.

1. Calvert Memorial Hospital2. Doctors Community Hospital3. Ft Washington Medical Center4. MedStar Southern Maryland Hospital5. MedStar St. Mary’s Hospital6. UMS Capital Regional Medical Center (formally Laurel Regional Hospital)7. UMS Capital Regional Medical Center (formally Prince George’s Hospital

Center)

Brief description of the Intervention2-3 sentences

The hospitals developed a standard community health worker (CHW) program and implemented it with the hospital staff, the eQHealth staff and the local departments of health. The training started in June 2017 and ended in October 2017. Thus we did not have many patients enrolled in TLC-MD that received the standard CHW program.

Participating Program Partners

1. PRINCE GEORGES DEPARTMENT OF HEALTH2. eQHealth RNs3. Individual employees of the hospitals.

Patients ServedPlease estimate using the Population category that best applies to the Intervention, from the CY 2017 RP Analytic Files.HSCRC acknowledges that the High Utilizer/Rising Risk or Payer designations may over-state the population, or may not entirely represent this intervention’s targeted population.Feel free to also include your partnership’s denominator.

# of Patients Served as of June 30, 2018: (As of CY 2017) 2,192

Hospital Patients with CHWDoctors - thru eQHealth 1,984

St Mary's - own staff 153

Calvert - own staff 17Ft Washington thru PGDH, Barbara Banks Williams -Dimensions thru PGDH, Barbara Banks Williams 38Total with CHWs 2,192

Denominator of Eligible Patients:2,628 TLC-MD population

3


Pre-Post Analysis for Intervention (optional)If available, RPs may submit a screenshot or other file format of the Intervention’s Pre-Post Analysis.

n/a

Intervention-Specific Outcome or Process Measures(optional)These are measures that may not have generic definitions across Partnerships or Interventions and that your Partnership maintains and uses to analyze performance.Examples may include: Patient satisfaction; % of referred patients who received Intervention; operationalized care teams; etc.

n/a

Successes of the Intervention in FY 2018Free Response, up to 1 Paragraph

This just began in late CY 2017, so we have no successes to discuss at this time.

Lessons Learned from the Intervention in FY 2018Free Response, up to 1 Paragraph

Although this just began in late CY 2017, all hospitals continue to say that having a standardized CHW program is best in our region due to patients and physicians overlapping among our hospitals.

Next Steps for the Intervention in FY 2019Free Response, up to 1 Paragraph

Complete the implementation of the standardized CHW program and evaluate where or not an RN doing both care coordination and CHW work (Doctors) is better, the same or worse than having a separate CHW. Also plan to evaluate the benefits of less re-admissions when a CHW is deployed.

Additional Free Response (Optional)

n/a

4


Intervention or Program Name 2. eQHealth Solutions for Care Management


1. Calvert Memorial Hospital2. Doctors Community Hospital3. Ft Washington Medical Center4. MedStar Southern Maryland Hospital5. MedStar St. Mary’s Hospital6. UMS Capital Regional Medical Center (formally Laurel




The hospitals developed a standard care management process. At first, only Prince George’s Hospitals utilized eQHealth thru the eQHealth nurses. During this year, we trained non-eQHealth staff employed at the hospitals to use eQHealth for case management and reporting to CRISP.

Participating Program Partners 1. eQHealth data group2. Individual employees of the hospitals.


# of Patients Served as of June 30, 2018: (As of CY 2017)1,964

Denominator of Eligible Patients:

120,912 TLC-MD population


The Pre-Post Analysis studies patients from the time of enrollment with TLC-MD as of 2014 who have a 6 month look back and a 6 month look forward with at least 1 hospital admission.

The Pre-Post Analysis (see Addendum 2) shows a reduction in total visits for both the ALL Hospitals chart and the TLC-MD ONLY Hospitals chart by 27% and 33%, respectively.

5


Charges that reduced substantially include:Medical Surgical Room and BoardEmergency room visitsLab and Rad services

However, the OR services and pharmaceutical charges did not reduce to the same percentage as total charge reductions, which was expected since these are not related usually to the potentially avoidable utilization.


n/a


This just began in late CY 2017, so we have no successes to discuss at this time.


Although this just began in late CY 2017, all hospitals continue to say that having a standardized care management program is best in our region due to patients and physicians overlapping among our hospitals.


Use the eQHealth system to document all RN and CHW activity to decide what hospital or process best serves our patients. Add other users, such as the pharmacy program and maybe the faith based users.

Additional Free Response (Optional) n/a

6



3. HQI Blue Bag Rx Program



Center)


The hospitals and HQI worked together to have the patients return unused drugs to their physicians’ offices for destroying. This is because patients might take the same drug during the day because they didn’t know it was the same. These over drug use can cause admissions and readmissions.


1. Physician offices2. Individual employees of the hospitals.


# of Patients Served as of June 30, 2018: (As of CY 2017) 51

Hospitals # of Blue BagsDCH 5St Mary's 6CalvertDimensions - two facilities 1Ft Washington 33Southern Maryland 6Total use of Blue Bags 51




The Pre-Post Analysis (see Addendum 3) shows a reduction in total visits for TLC-MD Hospitals for those patients using the Blue Bag Intervention (46%)

7


Charges that reduced substantially include:Medical Surgical Room and BoardEmergency room visitsLab and Rad services

However, the OR services and pharmaceutical charges did not reduce to the same percentage as total charge reductions, which was expected since these are not related usually to the potentially avoidable utilization


n/a


We used up all our FREE HQI bags and had to budget for purchasing more bags. This time we will have the TLC-MD and hospitals names on the bags.


Once bags were used up, the program started to end. We are actively to reboot the process with our custom bags.


Actively working with HQI rep, Tosin David, to reboot implementation with each facility. Need to identify Pharmacist champion at each facility. Working on refining data elements required for bag disbursements and monthly data collection sheets. Currently working on data extraction from eq to submit to HQI.


n/a

8


Intervention or Program Name 4. P3 Medication Adherence Program


1. Calvert Memorial Hospital2. Doctors Community Hospital3. Ft Washington Medical Center4. MedStar Southern Maryland Hospital5. MedStar St. Mary’s Hospital6. UMS Capital Regional Medical Center (formally Laurel




This program with UMS Pharmacy Department and MedChi offers patients the opportunity to have all of their medications reviewed to ensure the timing of their doses and the appropriateness of all their drugs. In addition, expiration dates and contra-indications, including supplements and herbals. There are so many opportunities for synergy; we can complement the medication therapy management services for eQHealth services since they do not have the pharmacist piece.

Participating Program Partners 1. eQHealth RNs2. Individual employees of the hospitals.3. UMS pharmacy department


Not started but had 10 people enrolled in a Calvert Memorial similar program.

Denominator of Eligible Patients: n/a


n/a

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n/a


Not started as planned, but Calvert Memorial is trying to develop the program using their own pharmacist.


Due to the Clinical Group re-thinking with the Data Group how to capture results, this project was put on hold.


Multiple planning calls held. CRISP cannot provide level of detail needed for MTM. eqHealth pharmacist assessment / survey tool shared with P3 staff for their review. Attempting to ID best way for medication list to be viewed by P3 staff. P3 has telephone and telehealth capabilities via secure Skype-type system. Multiple calls held and planned as we continue to work through P3 implementation. Hospital commitments to program still pending.

Additional Free Response (Optional) n/a

10



5. ASA Medication Adherence Tele Health Devices



Center)


The hospitals utilized remote monitoring devices as needed. Not too many devices were utilized during the year and by just a few hospitals.


1. eQHealth RNs2. Individual employees of the hospitals.


# of Patients Served as of June 30, 2018: (As of CY 2017) 31

Hospitals

Patients using Remote

Monitoring DCH 19 st Mary's - need figure 9 Calvert - Dimensions - two facilities - Ft Washington - Southern Maryland 3 Total Patients 31


Pre-Post Analysis for Intervention (optional)If available, RPs may submit a screenshot or other file format of the Intervention’s Pre-Post


The Pre-Post Analysis (see Addendum 5) shows a reduction in total visits (20%) for TLC-MD Hospitals for those patients using the ASA tele health devices.

11


Analysis.Charges that reduced substantially include:

Medical Surgical Room and BoardEmergency room visitsLab and Rad services

However, the OR services and pharmaceutical charges did not reduce to the same percentage as total charge reductions, which was expected since these are not related usually to the potentially avoidable utilization


n/a


None noted


Not too many devices were utilized. Problems with re-loading the drug dispensers have caused TLC-MD Clinical committee to re-think this part of our program.


Implemented with devices being incrementally deployed by most hospitals. All hospitals using to some extent. Establishing critical values thresholds for add-on devices has been a challenge.


n/a

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Core MeasuresPlease fill in this information with the latest available data from the in the CRS Portal Tools for Regional Partnerships. For each measure, specific data sources are suggested for your use– the Executive Dashboard for Regional Partnerships, or the CY 2017 RP Analytic File (please specify which source you are using for each of the outcome measures).

Utilization MeasuresMeasure in RFP(Table 1, Appendix A of the RFP)

Measure for FY 2018 Reporting Outcomes(s)

Total Hospital Cost per capita

Partnership IP Charges per capita

RP Executive Dashboard:‘Regional Partnership per Capita Utilization’ –Hospital Charges per Capita, reported as average 12 months of CY 2017

-or-

Analytic File:‘Charges’ over ‘Population’(Column E / Column C)

Using Executive Dash Board Dec 2017

All Payer$148

-or-used CY 2017

3+ IP or Obs>=24 Visits Medicare FFSCharges are $ 184,228,160 and Population is 120,912 has a per capita of $127

All PayerCharges are $ 2,262,691,560and Population is 1,245,567.00 has a per capita $151

Notes from CRISPThere are 2 reasons why these numbers are so different.

1. The executive dashboard shows all payer and you chose the Medicare 3+ visit subset

2. The executive dashboard shows monthly per capita measurements and the yearly RP analytic file shows yearly sums. So if you take the all payer total charges divide it by the population and divide that by 12.

3.

Total Discharges per 1,000

Executive Dashboard:‘Regional Partnership per Capita Utilization’ –Hospital Discharges per 1,000, reported as


All Payer7.00

-or-

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average 12 months of FY 2018

-or-

Analytic File:‘IPObs24Visits’ over ‘Population’(Column G / Column C)

3+ IP or Obs>=24 Visits Medicare FFS 10,319.00

IPObs24Visits

1450944 Population*12

0.007111922 7.11

times 1000

All Payer

110,831.00

IPObs24Visits

14946804 Population*120.00741503

7.42

times 1000

Notes from CRISPFor this calculation- you actually have to divide column G by 12* column C because the visits are summed across 12 months so the denominator is the potential population times 12.

Total Health Care Cost per person

Partnership TCOC per capita – Medicare

Total Cost of Care (Medicare CCW) Report ‘Regional Partnership Cost of Care’:‘Tab 4. PBPY Costs by Service Type’ – sorted for CY 2017 and Total

$11,299

ED Visits per capita

Ambulatory ED Visits per 1,000

RP Executive Dashboard:‘Regional Partnership per Capita Utilization’ –Ambulatory ED Visits per 1,000, reported as average 12 months of FY 2018

-or-


All Payer26

-or

3+ IP or Obs>=24 Visits Medicare FFS

5233 EDVisits1450944 Population*12

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Analytic File‘ED Visits’ over ‘Population’(Column H / Column C)

0.00360662 3.61 times 1000

All Payer 368,288

EDVisits

14,946,804

Population*12

2.46% 24.64

times 1000

Quality Indicator MeasuresMeasure in RFP(Table 1 in Appendix A of the RFP)


Readmissions

Unadjusted Readmission rate by Hospital (please be sure to filter to include all hospitals in your RP)

RP Executive Dashboard:‘[Partnership] Quality Indicators’ –Unadjusted Readmission Rate by Hospital, reported as average 12 months of FY 2018

-or-

Analytic File:‘IP Readmit’ over ‘EligibleforReadmit’(Column J / Column I)

Using Executive Dash Board Dec 2017All Payer11.4%

Or

3+ IP or Obs>=24 Visits Medicare FFS 2,393.00

IPReadmit

7652 EligibleforReadmit

31.27%

All payer 8,275.00

IPReadmit

76427 EligibleforReadmit

10.83%

15


PAU Potentially Avoidable Utilization

RP Executive Dashboard:‘[Partnership] Quality Indicators’ –Potentially Avoidable Utilization, reported as sum of 12 months of FY 2018

-or-

Analytic File:‘TotalPAUCharges’(Column K)

Using Executive Dash Board Dec 2017All Payer$22,581,435 per month, $270,977,220 per year

Or

3+ IP or Obs>=24 Visits Medicare FFS $ 66,234,182 used CY 2017 per year

All Payer$ 274,228,984 used CY 2017 per year

Notes from CRISPThe executive dashboard shows metrics for all payers. Also the executive dashboard is per month so you need to multiply it by 12 to get the yearly amount

CRISP Key Indicators (Optional) These process measures tracked by the CRISP Key Indicators are new, and HSCRC anticipates that these data will become more meaningful in future years.

Measure in RFP(Table 1 in Appendix A of the RFP)


Established Longitudinal Care Plan

% of patients with Care Plan recorded at CRISP

RP Executive Dashboard:‘High Needs Patients – CRISP Key Indicators’ –% of patients with Care Plan recorded at CRISP, reported as average monthly % for most recent six months of data

May also include Rising Needs Patients, if applicable in Partnership.


7.6%

Portion of Target Population with Contact from

Potentially Avoidable Utilization

RP Executive Dashboard:‘High Needs Patients – CRISP Key


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Assigned Care Manager

Indicators’ –% of patients with Case Manager (CM) recorded at CRISP, reported as average monthly % for most recent six months of data

May also include Rising Needs Patients, if applicable in Partnership.

38.5%

Self-Reported Process Measures - see Addendum 6Please describe any process measures that your RP is tracking, but are not currently captured under the Executive Dashboard. Some examples are including shared care plans, health risk assessments, patients with care manager who are not recorded in CRISP, etc. These can be by-intervention or by-partnership.

The TLC (all hospitals) patient enrollment summary indicates a gradual increase in patient enrollment but a flattening and decline as staff turnover affected enrollment over the late spring/summer timeframe. Staff has since been replaced and we are in the process of re-training new care coordinators in an on-site “boot camp” experience. The session will be recorded and will be used to create a standard operating procedure (SoP) to prevent any further decline in enrollment due to staff turnover. Detailed enrollment trend reports follow in Addendum 6 allowing us to identify area of specific hospital enrollment improvement opportunities.

17


Return on InvestmentIndicate how the Partnership is working to generate a positive return on investment (Free Response; please include your calculation). Please refer to the line-item definitions to complete the calculation by-intervention, if able.

[HSCRC is confirming by-intervention ROI calculation template]

The positive return on investment is a result of using your grant dollars to reduce the potentially avoidable utilization. The formula could be the total of 3 years of the grant divided by the PAU savings.

Definitions:

1) PAU savings over the 3 years as compared to base (in the 4th year back):

Based year PAU - $100,000,000

1st year - $95,000,000 (saved $5 million)

2nd year - $90,000,000 (saved $5 million)

3 rd year - $96,000,000 (lost $6 million)

Net savings is $4,000,000

2) Grant:

1st year - $1,200,000

2nd year - $1,000,000

3 rd year - $ 900,000

Total Grant $3.1 million

Example:

PAU savings $4,000,000 / $3,100,000 in 3 years of grant dollars = 1.29%, a 29% ROI

Do this on a rolling 3 year report each year.

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ConclusionPlease include any additional information you wish to share here. Free Response, 1-3 Paragraphs.

We have other efforts being unfunded by the hospitals that we are trying to bring into TLC-MD within our limited $1 million funding for 3 counties.

Physician Education & Collaboration (Dr. Chile Ahaghotu)

Presentation slide deck complete and in use. Dr. Chile met with CHMC VPMA to review slide deck and plan future presentation at CHMC. First presentation held at DCH, led by Dr. Chile and Ursula.

Faith-based Community Collaboration (John O’Brien)

Northern and Southern sub-coalitions continue to work on non-TLC directed activities. Target collaboration after 7/1/2018.

Physician Engagement Outcomes and Measures (Dr. Chile Ahaghotu)

Logic model requires addition of physician engagement outcomes. Several focused Clinical Committee Go-to Meetings held to determine target outcomes and recommended measures / data elements.

Payer Collaboration (Ashley Cunningham) Target initiation 7/1/2018. Reports under development (David

Chernov)See last Addendum

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Addendum 1: Community Health Worker Program

No Pre-Post this reporting period due to lack of full enrollment by all hospitals in this program; however, see last Addendum for reports under development for care coordination.

20


Addendum 2: Pre-Post Analysis for EqHealth Care Management

Pre/Post Analysis of 6 Months of Visits Before and After the Enrollment Date (All Hospitals) Total Number of Members in the

PanelNumber of Members with Data for

Pre/Post Analysis Breakdown of Charges of 6 Months of Visits Before and After the Enrollment Date (All Hospitals)Most Recent Payer

Visit Type

All

21

2,345


Breakdown of Charges SheetHospital Name

Pre/Post Analysis of 6 Months of Visits Before and After the Enrollment Date (TLC Only) Total Number of Members in the

PanelNumber of Members with Data for

22

2,345


Pre/Post Analysis Breakdown of Charges of 6 Months of Visits Before and After the Enrollment Date (TLC Only)

Most Recent Payer

Visit Type

All


23


Addendum 3: HQI Blue Bag Rx Program

Pre/Post Analysis of 6 Months of Visits Before and After the Enrollment DateTotal Number of Members in the

Panel

Number of Members with Data for

24

166


All


25


Addendum 4: P3 Medication Adherence ProgramNo Pre-Post this reporting period due to lack of full hospital participation in this program.

26


Addendum 5: ASA Medication Adherence Tele Health Devices

27


28


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HSCRC Transformation Grant – Performance Year 2 (FY 2018) Report Template - DRAFT

Addendum 6: Self-Reported Process Measures

Enrollment Summary: TLC-MD

Prior Yrs

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1383

189

134

152

174

190

170 23

1

197 25

3

179

170

120

100 14

0

12379

72 60 53 78 110

138

156

119

98 184

177

269

178

241

10

Enrolled

Disenrolled

Active Enrollees

30


Enrollment Summary: Calvert Memorial Hospital

Prior Yrs

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

0

50

100

150

200

250

300

350

4 5

21

12

20

39

2527

32

45

39

25

30

2427

31 0 2 2 2 2 1 3 9 2 3 8 2 2 15 1

Enrolled

Disenrolled

Active Enrollees

31


Enrollment Summary: Doctor’s Hospital

Prior Yrs

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

0

200

400

600

800

1000

1200

1400

1345

129

60 58 64 65 62 105

88 115

56 44 48 47 34 4369

70 46 38 51 54 107

75 66 69 114

133

200

132

118

4

Enrolled

Disenrolled

Active Enrollees

32


Enrollment Summary: Fort Washington Hospital

Prior Yrs

Jul-17 Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18 Aug-18

Sep-18

0

20

40

60

80

100

120

140

4 5 6

22

1 1

6

17

23

12

1

36

2 1 8

Enrolled

Disenrolled

Active Enrollees

33


Enrollment Summary: Prince Georges Hospital

Prior Yrs

Jul-17 Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18 Aug-18

Sep-18

0

2

4

6

8

10

12

16

1 1 1

3

1

6

7 1 1 1 1 2 6

Enrolled

Disenrolled

Active Enrollees

34


Enrollment Summary: Southern Maryland Hospital

Prior Yrs

Jul-17 Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18 Aug-18

Sep-18

0

50

100

150

200

250

300

1

10

16

22

29 29

19

59

51 49

41

69

29

26

23

0 2 4 2 8 6 9 16 20 14 37 31 36 24 46 5

Enrolled

Disenrolled

Active Enrollees

35


Enrollment Summary: St. Mary’s Hospital

Prior Yrs

Jul-17 Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18 Aug-18

Sep-18

0

50

100

150

200

250

13

44

37

54 55

35

63

39

20

27

19 17

12

2

14

5

7 11 17 47 21 62 24 12 29 4 29 14 54

Enrolled

Disenrolled

Active Enrollees

36


Addendum 7: Reports under Development:

1) Adherence Survey Supporting Logic Model

Unique Members: 107 Responses

Survey Question No YesGrand Total

Is the patient adherent with their diagnostic plan (lab work/imaging)? 35 73 108Is the patient adherent with their medication plan? 33 76 109Is the patient adherent with their nutrition plan? 32 73 105Is the patient adherent with their PCP appointments? 46 63 109

Grand Total 14628

5 431

Unique Members: 107 Responses

Hospital No YesGrand Total

Calvert Memorial Hospital 128 85 213Is the patient adherent with their diagnostic plan (lab work/imaging)? 31 23 54Is the patient adherent with their medication plan? 31 23 54Is the patient adherent with their nutrition plan? 26 25 51Is the patient adherent with their PCP appointments? 40 14 54

Doctor's Hospital 1214

4 156Is the patient adherent with their diagnostic plan (lab work/imaging)? 4 35 39Is the patient adherent with their medication plan? 1 38 39Is the patient adherent with their nutrition plan? 3 36 39

37


Is the patient adherent with their PCP appointments? 4 35 39Fort Washington Hospital 1 3 4

Is the patient adherent with their diagnostic plan (lab work/imaging)? 1 1Is the patient adherent with their medication plan? 1 1Is the patient adherent with their nutrition plan? 1 1Is the patient adherent with their PCP appointments? 1 1

Southern Maryland Hospital 1 34 35Is the patient adherent with their diagnostic plan (lab work/imaging)? 8 8Is the patient adherent with their medication plan? 9 9Is the patient adherent with their nutrition plan? 9 9Is the patient adherent with their PCP appointments? 1 8 9

St. Mary's Hospital 4 19 23Is the patient adherent with their diagnostic plan (lab work/imaging)? 6 6Is the patient adherent with their medication plan? 1 5 6Is the patient adherent with their nutrition plan? 2 3 5Is the patient adherent with their PCP appointments? 1 5 6

Grand Total 14628

5 431

2) Vit. D Survey to all patients enrolled

Question 1

No Yes Grand Total

Have you ever had your Vitamin D level checked? 111 200 311

Question 2, if responded "Yes" to Question 1

No Yes Grand Total

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Do you know what the result was? 192 8 200

Question 3, if responded "Yes" to Question 2Response

sEnter Vitamin D level 8

does not know value except that it was previously low1

low 3lower than it should have been 1previous reading was low. Not currently taking a

supplement1

unk 1unknown number but it was low 1

Question 4

No Yes Grand Total

Are you currently taking Vitamin D? 227 88 315

Question 5, if responded "Yes" to Question 4Response

sHow much Vitamin D are you taking and how often? 86

1,000 units daily 11,000 units every evening 11,000mg daily 11.25 weekly 11000 IU daily 21000 units Daily 1

39


1000 units daily 31000iu/day 11000mg daily 11000mg or 3000mg a day, something like that, it's in a

green bottle1

1000u BID 11200 softgel 12 tabs daily, she thinks 1000 units/each 12,000 UNITS/DAILY 12000 units daily 2200mg daily 1400 units daily 150 000 IU weekly 150 000 u by mouth every week 150 000 units once a week 150,000 u weekly 150,000 units every two weeks 150,000 units PO weekly 150,000 units weekly 150,000 units/week 150,000 units/weekly 150,000 units/weekly (has 1 dose remaining) 1500mg D3 every day 1600 mg daily 1BIW at dialysis; unk dosage 1Calciferol 50,000u monthly 1Calcitriol 0.125 mcg per day Ergocalciferol

50,000 u per week1

Calcitrol one daily 1Calcium 600mg and Vit D 400mg daily 1Calcium Carb with Vit D 800 1

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Cholecalciferol 2,00mg per day 1cholecalciferol 5,000u daily 1Citracel + D250mg 1D2 1.25 mg weekly 1D3 1,000 units per day 1D3 1.25 weekly 1D3 2,000 mg per day 1D3 50,000 units per day 1D3 50,000u weekly 1D3 50mcg daily 1Does not know, is over the counter. 1Ergocalcalciferol 1.25 every seven days 1Ergocalceferol unk dose daily 1Ergocalcifritol 50,000 units weekly 1Hematologist monitors lab for member due to the

myasthenia gravis. Takes 2000 IU, 1 daily1

I take it on my own ; unk dosage 1Member is pregnant & is taking prenatal vitamins 1Member not taking Vit D supplements at this time. 1Member takes Calcium with Vitamin D daily. 1Member unsure of amount and states prescription is

currently being filled at pharmacy.1

multivitamin 1once a week 1Oscal BID 1OTC 1takes calcium + vit D daily 1takes daily, unk dose, member was to have med ready

when CC called back but he did not1

Takes it daily. Unsure of dosage. Reports her calcium pills have vitamin D.

1

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takes weekly 1unknown by member 1Unknown dosage of Vit D every other week 1unknown dose 1unkown 1Unsure of the dosage, takes a daily Vit D supplement

as recommended by her MD1

unsure, he receives it at dialysis 1Vit D 5,000 units weekly 1Vit D 50,000u per week 1Vit D2 1.25 weekly 1Vit D2 50,000 units 2xweek 1Vit D2 50,000 Units once per week for 12 weeks. 1Vit D2 50,000u weekly 1Vit D21.25 weekly Vit D3 5,000u daily 1Vit D3 5,000u daily 1Vit D3 500mg daily with calcium 1Vitamin D 10,000 mg daily. 1Vitamin D with calcium twice daily (unable to verify

dosage)1

Vitamin D2 50,000u weekly 1Vitamin D3 1000 units po daily 1

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3) Short-Term & Long-Term Outcomes Measures

Outcome Measures Outcomes

TypeCompleted (Follow Up

Needed)

Not Resolved

Partially Resolved

Resolved

Grand Total

Mid-Term Outcome Measures 52 2 67 121Complete Adherence with Medical Plan Survey 12 1 35 48Ensure patient has received Vitamin D level screening 11 23 34Ensure patient is engaged in at least one TLC medication adherence initiative 29 1 9 39

Short Term Outcome Measures 1 25 117 143Ensure patient has coherent eQHealth medical plan 1 6 51 58Ensure patient has resources to self-manage their care 9 51 60Perform successful coaching call 5 10 15 25Grand Total 1 77 2 184 264

Outcome Measures Outcomes

TypeCompleted (Follow Up

Needed)

Not Resolved

Partially Resolved

Resolved

Grand Total

Calvert Memorial Hospital 1 49 50Mid-Term Outcome Measures 8 8Complete Adherence with Medical Plan Survey 8 8Short Term Outcome Measures 1 41 42Ensure patient has coherent eQHealth medical plan 1 10 11Ensure patient has resources to self-manage their care 22 22Perform successful coaching call 5 9 9Doctor's Hospital 59 2 67 128

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Mid-Term Outcome Measures 40 2 22 64Complete Adherence with Medical Plan Survey 9 1 10 20Ensure patient has received Vitamin D level screening 9 10 19Ensure patient is engaged in at least one TLC medication adherence initiative 22 1 2 25

Short Term Outcome Measures 19 45 64Ensure patient has coherent eQHealth medical plan 4 27 31Ensure patient has resources to self-manage their care 7 15 22Perform successful coaching call 5 8 3 11Fort Washington Hospital 1 2 3Mid-Term Outcome Measures 1 1 2Complete Adherence with Medical Plan Survey 1 1Ensure patient is engaged in at least one TLC medication adherence initiative 1 1

Short Term Outcome Measures 1 1Ensure patient has coherent eQHealth medical plan 1 1Prince Georges Hospital 6 6Mid-Term Outcome Measures 3 3Complete Adherence with Medical Plan Survey 1 1Ensure patient has received Vitamin D level screening 1 1Ensure patient is engaged in at least one TLC medication adherence initiative 1 1

Short Term Outcome Measures 3 3Ensure patient has coherent eQHealth medical plan 1 1Ensure patient has resources to self-manage their care 1 1Perform successful coaching call 5 1 1Southern Maryland Hospital 5 19 24Mid-Term Outcome Measures 5 8 13Complete Adherence with Medical Plan Survey 1 4 5Ensure patient has received Vitamin D level screening 4 4Ensure patient is engaged in at least one TLC medication adherence initiative 4 4

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Short Term Outcome Measures 11 11Ensure patient has coherent eQHealth medical plan 5 5Ensure patient has resources to self-manage their care 5 5Perform successful coaching call 5 1 1St. Mary's Hospital 6 47 53Mid-Term Outcome Measures 3 28 31Complete Adherence with Medical Plan Survey 1 12 13Ensure patient has received Vitamin D level screening 1 9 10Ensure patient is engaged in at least one TLC medication adherence initiative 1 7 8

Short Term Outcome Measures 3 19 22Ensure patient has coherent eQHealth medical plan 1 8 9Ensure patient has resources to self-manage their care 1 9 10Perform successful coaching call 5 1 2 3Grand Total 1 77 2 184 264

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Documents

Regional Partnership Information - Maryland · Web viewProgram Partners in FY 2018 Please list any community based organizations, contractors, and/or public partners AUTOMATED SECURITY